76-year-old woman with known HF, chronic kidney disease, and atrial fibrillation.
Complaint: sudden severe breathlessness overnight; now sitting upright, unable to speak full sentences. History: two days of increasing orthopnea, no known fever, medicines include a loop diuretic and rate-control. Exam: anxious, diaphoretic, widespread bilateral crackles, accessory-muscle use, cool distal fingers but awake, marked respiratory distress.
Vitals: HR 128 irregular · BP 168/96 · RR 34 · SpO₂ 84% (room air)
Labs: ECG: AF with rapid ventricular response · CXR: pulmonary edema pattern · renal/electrolytes pending
What do you notice?
